OB-Gone

We're losing ob-gyn docs and not gaining new ones. What gives?

By the end of December, there will be just five OB-GYN (obstetrics and gynecology) physicians left in Humboldt County — down from at least 10 just four years ago. And of those who remain, four are older than 60 and only one sees patients in his office full time: Deepak Stokes, 64, who practices in Eureka.

Two others — Jack Anderson, 69, Fortuna's sole OB-GYN physician now; and Oliver Puttler, 73, in Arcata — are working just over three-quarter time. A third, Keven Nevil, 42, practices just over half time in Arcata. And William Koch, 64, stopped taking patients in an office after he began working as a hospital laborist in June, strictly focusing on deliveries.

In addition, in the past year, not a single new OB-GYN has moved in.

This in a county of 135,000, which by one measure should have 13 or 14 OB-GYN docs, according to Heather Shelton, spokesperson for the Humboldt County Department of Health and Human Services. Shelton said she'd seen a recommended ratio of roughly one OB-GYN doctor for every 10,000 residents in the New England Journal of Medicine.

"Patients who need a critical level of care will soon face a doctor who is much more stressed and less supported than previously," says Cherrie Andersen, one of the OB-GYNs who will be leaving Humboldt at the end of the year. "I think it is a matter of time until disaster happens."

What's happening in Humboldt is partly a reflection of national trends like the aging physician population and the increasing allure of higher-paying specialties. But there are localized factors at play, too. Some providers say changes being made or considered by the St. Joseph Health System are making it harder to recruit new doctors to see the roughly 1,500 women who give birth in Humboldt each year.

St. Joseph Hospital in Eureka and Redwood Memorial Hospital in Fortuna are both part of the St. Joseph system, which is owned by the Catholic Sisters of Orange based in Orange County. In 2012, the health system announced it was stopping sterilizations in its hospitals, no matter the woman's age, psychological condition or potential for grave health risks in subsequent pregnancies. No longer would a woman be able to have her tubes tied right after giving birth, a practice that eliminates the need for a second surgery later. At the time, Dr. William Weiderman resigned his post as OB-GYN director at St. Joseph, although he continued to see patients. Now, he is closing his practice in Eureka to go on sabbatical next year to New Zealand. According to Penny Figas, executive director of the Humboldt-Del Norte Medical Society, others have left in part because of the ban, including Eureka OB-GYN Gita Meshri, who worked in Stokes' practice but left in August for Oklahoma.

The sterilization ban may also be impeding recruitment. "No gynecologist will give up the ability to prescribe birth control for a job," says Andersen, who has taken a job in Yakima, Wash.

Leslie Broomall, spokesperson for St. Joseph, declined to comment on whether the sterilization policy is keeping anyone away. The hospital is "actively recruiting new OB/GYN physicians to the community," she wrote in an email.

In addition, she wrote that although tubal ligations (and vasectomies and abortions) are prohibited at the two Catholic hospitals, "physicians in private practice can make arrangements for those procedures at neighboring hospitals and clinics. ... Private practice physicians can still have hospital privileges at St. Joe's and Redwood Memorial if they choose to perform those procedures elsewhere."

The St. Joseph Health System also is considering closing its Fortuna birth center and shifting all deliveries to Eureka, to increase efficiency and cope with the dwindling number of OB-GYN docs. Although Broomall wrote that no final decision has been made, and that there would be a community forum soon to discuss it, the proposal has provoked outcry in the southern half of Humboldt County, from Whitethorn to Fortuna.

"They need to be cautious how they do this," says Stephanie Dittmer, a family practitioner at Humboldt Medical Group in Fortuna with specialized training in obstetrics. Dittmer, who backs up OB-GYN doctor Jack Anderson once a week, worries that women in far-flung southern regions will have to go that much farther when they're in labor.

"More babies might be delivered on the way to the hospital," she says.

Anderson put it more bluntly: "We're sort of Fort Apache down here. I think we're desperately needed. Get rid of the OB program here and eventually it's going to cost lives because of the additional travel time for some women to get to Eureka."

He says Redwood Memorial's obstetrics program needn't, and shouldn't, be closed. It's a popular program, he says, that opened in the 1950s and has been around longer than St. Joseph Hospital's. It scores high in national patient surveys. And the community has a strong sense of ownership of it, Anderson says.

"They had the benefit ball the other night and raised $230,000 in one night for the hospital," he says. "People really like their little hospital here."

Closing the birth center in Fortuna might, in fact, snowball the OB-GYN exodus.

Although nurse midwives and family practitioners specializing in obstetrics can take some pressure off the thinly stretched OB-GYN physicians, under California law they must have an OB-GYN physician available within 30 minutes of the hospital to back them up for complications in birth.

Dittmer, whose passion is obstetrics, says she doesn't know if she'll stay if Redwood Memorial's birth center closes. There are studies, she says, that show that rural communities are most successful in keeping their doctors if they recruit ones who want that specific area. That's how it was with her and Fortuna.

"This is the community that drew us here. It's the place I can hike in the redwoods, it's the place I can go to the beach, it's the place where I can go fishing, it's the place where my husband can go crabbing."

It's also the place, she says, where she can be at work one moment and, on a break, be at a special event at her daughter's school the next.

"Practicing in a clinic here in Fortuna is what I came to do," she says. "I don't want to commute. I want to be here."

Same with Jack Anderson, who's been delivering Fortuna babies for more than three decades.

"If they close it, I'll quit OB in this area," he says. "Maybe I'll just do locum tenens — go out and fill in for people. ... And I'm not sure what the midwives [at Redwood Women's Center] would do. But the county could potentially lose five OB-practicing people."

Meanwhile, birthing patterns in Humboldt may be shifting, with more deliveries taking place at Mad River Hospital in Arcata, according to the Automated Vital Statistics System, provided by Humboldt County's Department of Health and Human Services. In 2011, there were 628 births at St. Joseph, 463 at Mad River, 330 at Redwood Memorial, 66 at home and five elsewhere (in an ambulance, car, hotel, etc.). In 2012, births at St. Joseph dropped slightly to 595 and Mad River increased more sharply, to 540. There were also 370 births at Redwood Memorial, 52 at home, one at Jerold Phelps Community Hospital in Garberville and three elsewhere. This year, through Nov. 20, there were 1,337 births and so far Mad River has seen more of them than St. Joe's. The totals to date are 491 births at St. Joseph, 504 at Mad River, 304 at Redwood Memorial, 34 at home, one at Jerold Phelps Community Hospital in Garberville and three elsewhere.

Mad River administrators did not respond immediately to requests for comments on this shift.

As the birthing picture in Humboldt continues to evolve, another key piece in the scenario is the potential loss of the laborist program at St. Joseph, which is staffed by midwives and physicians. Laborists can help ease the strain on other OB-GYN doctors by reducing on-call demands. That means more time can be spent, say, hiking in the woods or sipping a glass of wine instead of being stone cold sober and available to show up at the hospital within 30 minutes. Cherrie Andersen says she was recruited four years ago by St. Joseph to be a hospital laborist while also seeing patients at one of the two OB-GYN groups in Eureka, the Center for Women's Health Care. But then the OB-GYNs in her group began dropping out — retiring, leaving town. It was just her and William Koch, finally. He quit taking his own patients and went to work solely as a laborist at St. Joseph. Andersen tried to survive in private practice; that didn't work out for financial and personal reasons. The center closed in June and Andersen continued to work as a laborist for the hospital.

"Then the hospital began to make noise about not funding the laborist program," she says. She says the program keeps getting extensions to stay open, but she doesn't know if it will last.

"I finally decided to find work elsewhere so I could have some peace of mind," she says. At the end of the year, she'll move to Yakima where she'll have full-time work as a laborist.

The uncertainties create an ironic feedback loop, it seems, at least in Jack Anderson's case.

"The hospital's much more concerned about me getting additional people here than I am," he says. "They've said I can't attract a partner here. Well, that's a nonstarter, because I don't have a stable platform from which to do that. In a stable situation, I can attract another OB-GYN here in a New York minute."

The other doctors mentioned in this story did not respond to requests for interviews.